Occ Disease Form

If you require assistance or have an issue related to a claim recognized as being an occupational disease, and you would like it reviewed by the OPFFA's Occupational Disease Committee, please fill out the form below and a member will get back to you as soon as possible.

All information entered on this form is confidential and will not be shared with anyone outside of the OPFFA.

Please contact the OPFFA's Occupational Disease Committee Chair with any questions.

Request for Occupational Disease Committee Assistance:

* Indicates required field

Name - person filling out form *

First

Last

Email *

Phone Number *

Local City Name: *

IAFF Local Number: *

Name - Local's Advocate: *

First

Last

Assistance Required for: *

Other: *

Worker Name: *

First

Last

Worker Date of Birth: *

Worker Phone: *

Worker Email: *

Permission to Contact Worker? *

Yes No

Upload Files: *

Max file size: 20MB

Please give us as much information as possible on the situation: *

Additional Comments: *

Submit